Remote Filling Verification - Click on 2 Different Errors
37598012
4/3/20XX
William Hanson
James Warren
Chew and swallow one tablet by mouth three times daily for
10 days.
Amoxil 250 mg Chewable Tablets
30
0
4/3/20XX
SKB
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 1
Drug NDC: 00029-6005-30
Quantity: 30
Days Supply: 10
AWP Cost/Unit: $0.72
Total Drug Cost: $21.60
Dispensing Fee: $2.00
Total Billed: $23.60
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 1
Drug NDC: 00029-6005-30
Quantity: 30
Days Supply: 10
AWP Cost/Unit: $0.72
Total Drug Cost: $21.60
Dispensing Fee: $2.00
Total Billed: $23.60
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 37598012
Dispensing Date: 3/4/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 4/3/20XX
Initials: RPh
Drug Manu: SKB
Rx Documentation
Dispensing Date: 3/4/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 4/3/20XX
Initials: RPh
Drug Manu: SKB
